By submitting this claims form and any accompanying documentation, I understand and agree that:

The information provided on this form and in any accompanying documentation is true and accurate to the best of my knowledge.

The policyholder and/or the claimant authorize the release of any medical or other information necessary for the processing of this claim.

The policyholder and/or the claimants authorize the insurance company and its representatives to investigate this claim, including but not limited to: contacting medical providers, employers, and other insurance companies.

The policyholder and/or the claimants understand that the submission of this claim does not guarantee payment and that any payments made will be based on the terms of the policy and applicable laws.

The policyholder and/or the claimants authorize the insurance company to discuss the claim with the insurance agent/broker who sold the policy.

The policyholder and/or the claimants authorize the insurance company to use and store the personal data provided in this form, as well as any documents submitted, for the purpose of processing the claim and in accordance with the company's privacy policy.

The policyholder and/or the claimants confirm that they have read and understand the above statement and that the information provided is accurate and complete to the best of their knowledge.